Interventions

The last part of pain management is the procedures and interventions. For anesthesia residents, this is one of the more exciting facets of pain medicine. We can target peripheral nerves with anesthetic, steroid, or radiofrequency modulation. From intercostal nerves to pudendal nerves to spinal nerves, we can get to most targets with a good knowledge of anatomy and an ultrasound machine or C-arm X-ray. Sometimes, we target complexes of nerves called ganglia; we can ablate the celiac plexus, lumbar sympathetic plexus, and Gasserian ganglia. We also perform procedures on or near the spine; epidural steroid injections are a mainstay of therapy as well as the placement of intrathecal catheters and pumps.

The procedures are quite enjoyable and educational. We perform epidurals on obstetric patients all the time, but here, we guide it with X-rays and fluoroscopy. This allows us to really understand the anatomy, see pathologic variants, and become fluent with how to address problems. Comparing three dimensional models to our two dimensional X-rays challenges us to visualize the anatomy of nerves and surrounding structures. For the most part these procedures are fast, so we do many each day, allowing us to see a range of different disease states.

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